Which one first? Barium enema or colonoscopy

Barium enema and colonoscopy share common problems, including patient preparation and cooperation, technical difficulties in reaching the cecum, and variables relating to the expertise of the person performing the procedure. On the other hand, it has been well documented that colonoscopy has the advantage of detecting a larger number of lesions and smaller lesions, and the ability to be therapeutic as well as diagnostic. Colonoscopy also guides the surgeon in doing proper resections, based on tissue diagnoses, in cases when there are several lesions in different locations in colon. When colon lesions are suspected, barium enema as the first diagnostic procedure means that the patient must undergo a second bowel preparation prior to colonoscopy. Thus, instead of using colonoscopy to confirm or rule out the findings, the most logical approach is to do colonoscopy first, which avoids the repetition of bowel preparation and the cost of barium enema. If colonoscopy cannot be performed, or cannot be completed to the cecum, then the next best choice is to proceed to double contrast barium enema.